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Content Outline (TOC)
Supporting the healthcare workforce
during COVID-19: A 3-tiered intervention framework
David Cates, Ph.D.
Director, Behavioral Health, Nebraska Medicine
Vice Chair of Clinical Operations, UNMC
Content Outline (TOC)
No conflicts of interest
No disclosures
Supporting the healthcare workforce
Challenges for healthcare workers (HCWs) in a pandemic
Agenda
Psychological distress among HCWs
Obstacles to supporting HCWs
3-Tier framework for workforce support
Strategies within each tier
Ongoing support after the pandemic
HCW Challenges in a Pandemic
■ PPE - Proper use, discomfort ■ Infection control protocols
■ Fear of contracting the illness ■ Safety of family and friends
■ Limited resources (including testing) ■ Changes in workflow and responsibility
■ Lack of organization and role clarity ■ Separation from usual colleagues
■ Witnessing the death of patients ■ Illness and death in colleagues
■ Stigmatization, lack of appreciation ■ Working with new/unfamiliar colleagues
■ Prolonged uncertainty / anxiety ■ Self-doubt
■ Inadequate staffing / surge of patients
■ Feeling misunderstood; pressure to justify work
■ Increased workload and limited rest time; fatigue
■ Moral injury: Altered standards of care and ethical challenges (including visitation policies)
Supporting the healthcare workforce
Psychological Distress
Increased challenges Increased distress
• Most healthcare workers are resilient and will not experience lasting distress• However, depending on stress during the response, some are at risk for a new disorder
they didn’t have before the event
Posttraumatic stress Insomnia Alcohol/drug use
Depression Anxiety
• Symptoms may appear after the outbreak is under control
HCW Psychological Distress: COVID-19
Study Population Sample Findings
He, K., Stolarski, A., Whang, E., et al. (2020). Journal of Surgical Education.
Qualitative study of general surgery residents in 2 Boston academic medical centers
Concerns: health of family (100%) • transmitting COVID-19 to family (80%) • transmitting COVID-19 to patients (63%) • anticipated overwork (50%) • acquiring COVID-19 from patients (27%)
Kapila, A., Farid, Y., Kapila, V., et al. (2020). The British Journal of Surgery.
National survey of surgical residents inBelgium (n=123)
56% reported psychological strain as a result of the pandemic
Barello, S., Palamenghi, L., & Graffigna, G. (2020). Psychiatry Research.
376 HCWs in Italy during peak of pandemic
60% reported moderate or high levels of emotional exhaustion (on MBI) • 59% increased irritability • 55% difficulty sleeping • 48% muscle tension
Lu, W., Wang, H. Lin, Y., et al. (2020). Psychiatry Research.
2,299 HCWs in a hospital in South China during peak of pandemic
70% of medical staff reported moderate to extreme fear•12% mild to moderate depression
Sharma, M., Creutzfeldt, C., Lewis, A.,et al. (2020). Clinical Infectious Diseases.
1,651 ICU HCWs from all 50 states between April 23 and May 7, 2020 (initial peak in many states)
Concern about transmission to family (66%) • concern about own health (49%) • emotional distress/burnout (58%)
Lai, J., Ma, S., Wang, Y., et al. (2019). JAMA Network Open.
1,257 HCWs from 34 hospitals in China, Jan 29 - Feb 3 (rapid rise in COVID cases)
Moderate-to-severe: distress (35%) • depression (15%) • anxiety (12%) • insomnia (8%)
Cénat, J., Blais-Rochette, C., Kossigan, C., et al. (2021). Psychiatry Research.
Systematic review and meta-analysis of symptoms among HCWs and general public during COVID.
Depression 14% • Anxiety 15% • Insomnia 37% • PTSD 21% • Psychological distress 17% • Prevalence of insomnia in HCWs > general public
HCW Psychological Distress: Previous Outbreaks
Study Population Findings
Chong, M., Wang, W., Hsieh, W., et al. (2004). British Journal of Psychiatry.
1,257 HCWs in Taiwan during peak of SARS outbreak
75% psychiatric morbidity (anxiety, depression, somatic symptoms) • high levels of distress
Goulia,P., Mantas, C., Dimitroula, D., et al. (2010). BMC Infectious Diseases.
469 HCWs in a Greek hospital during the A/H1N1 (swine flu) pandemic
21% mild to moderate psychological distress • 56.7% moderately high worry • most frequent concerns were infecting family/friends and health consequences
Maunder, R., Lancee, W., Balderson, K., et al. (2006). Emerging Infectious Diseases.
769 HCWs in Ontario (Canada)hospitals during the SARS outbreak
HCWs who treated SARS patients 1-2 years later: 30% emotional exhaustion • 45% high psychological distress • 14% posttraumatic stress • higher rates than HCWs who did not treat SARS
Chan, A. & Huak, C. (2004). Occupational Medicine.
661 HCWs in a Singapore hospital two months into SARS pandemic
27% psychiatric morbidity • 20% reported symptoms indicative of posttraumatic stress disorder
Bai, Y., Lin, C., Lin, C., et al. (2004). Psychiatric Services.
338 workers in an East Taiwan hospital during the SARS outbreak
20% felt stigmatized • 15% reported exhaustion • 13% reported anxiety
Lee, S., Kang, W., Cho, A., et al. (2018). Comprehensive Psychiatry.
359 HCWs in a Korean hospital during the MERS outbreak
51% exceeded cut-off for PTSD on IES-R • 64% showed PTSD-like symptoms • In many cases, symptoms persisted for at least 6 weeks
Supporting the healthcare workforce
HCW Psychological Distress: COVID-19
Conclusion and Call to Action:
20-70% of healthcare workers experience severe emotional distress during highly hazardous communicable disease outbreaks, and for many the distress continues after the outbreak
Supporting the healthcare workforce
Psychological Distress
Selected modifiable risk factors
• Perception of heightened risk of infection
• Longer duration of high-risk exposure
• Inadequate PPE
• Excessive work hours
• Stigma from community
• Poor communication with supervisors
• Lack of social support
Social Support
Across measurement approaches, gender, age and country of origin, those who are less socially connected are at greater risk for early mortality.
Social disconnection is at least as harmful as physical inactivity, obesity, and smoking up to 15 cigarettes a day
Source: Holt-Lunstad, Robles, & Sbarra (2017). Advancing social connection as a public health priority in the Unites States, American Psychologist, 72, 517-530.
Essential in building resilience
Buffers the effects of stress
Social Support
Supporting the healthcare workforce
Workforce Support Evidence Base
• Limited research
• Based on descriptions in the literature, direct experience, contact with other institutions and user preferences
• Team effort
• Dr. Sarah Richards, Senior Medical Director, Care Experience, Nebraska Medicine
• Dr. Steven Wengel, Assistant Vice Chancellor for Campus Wellness, UNMC
• Dr. Jerry Walker, Psychology Services Manager, Nebraska Medicine
Evidence-based practice
Framework for Workforce Support
Tier 3:
Tier 1:
Indicated interventions
Universal interventions
UK’s National Health Service model for workforce support
Source: The British Psychological Society (2020). The psychological needs of healthcare staff as a result of the Coronavirus outbreak.
Framework for Workforce Support
Tier 3:
Tier 2:
Tier 1:
Indicated interventions
Selective interventions
Universal interventions
Mental health treatment
Screening and support for those at higher risk
Broad-based support for all members of the health system
Source: Committee on Post-Disaster Recovery of a Community’s Public Health, Medical, and Social Services. (2015). Healthy, resilient, and sustainable communities after disasters: Strategies, opportunities, and planning for recovery. Washington, DC: National Academies Press.
Obstacles to Supporting HCWs
• HCWs often minimize their distress• “Emotional labor”• Sometimes necessary• Culture of heroes • Unlikely to seek services
• Concerns about confidentiality• Inconvenience / insufficient time• Lack of awareness of services• Cost• Stigma
Therefore, programs and services should be:
• Proactive – we can't wait for HCWs to come to us• Embedded in existing environments• Highly visible• Easily accessible• Confidential• Nonstigmatizing
Framework for Workforce Support
Consider entire workforce, including supply chain, environmental services, lab, IT, security, etc.
Leadership principles and strategies
Resilience and stress management training
Centralized repository of psychoeducational resources
Universal peer support
Leadership
“When people are stressed and upset, they want to know that you care before they care what you know.”
— Will Rogers
Leadership
HCW need Key components of leadership response
Prepare me
• Clear, current, reliable, reassuring and honest information via regular town halls, staff meetings, email, video messages, etc.
• Training to support critical knowledge• Timely information about caring for COVID patients • Access to experts (e.g., PPE extenders) • Daily digest that links to comprehensive resource page • Model self-care and help-seeking
Hear me
• Feedback channels for 2-way communication• Include HCWs in decision-making and creating new protocols• Validate stress and mental health effects• Express awareness of and gratitude for the work• Examples: Town halls with Q&A, visiting hospital units, meeting with teams, listening
sessions, etc.
Adapted from Shanafelt, T., Ripp, J., & Trockel, M. (2020). Understanding and addressing sources of anxiety among health care professionals during the COVID-19 Pandemic. JAMA. doi:10.1001/jama.2020.5893.
Leadership
Adapted from Shanafelt, T., Ripp, J., & Trockel, M. (2020). Understanding and addressing sources of anxiety among health care professionals during the COVID-19 Pandemic. JAMA. doi:10.1001/jama.2020.5893.
HCW need Key components of leadership response
Protect me
• Adequate PPE• Rapid access to employee health with efficient evaluation and testing• Information and resources regarding staying safe• Accommodations for HCW’s at high risk
Support me
• Access to healthy meals and hydration while working• For those putting in long hours, consider lodging, transportation (if sleep-deprived), childcare (also for school
closures), meals, laundry service, cleaning service, etc.• Psychological support via webinars and directly to units• Wellness groups like yoga, mindfulness, healthy cooking, fitness • Individual support for those experiencing greater distress• Town Halls for family members of HCWs to address fears, risks, coping strategies and planning for
contingencies
Care for me
• For HCWs in quarantine or isolation, consider lodging, meals, childcare, and emotional/psychological support• Reinforce self-care and normalize symptoms of stress and help-seeking• Communicate that no one needs to make difficult decisions alone• Acknowledge fallibility
Leadership
• Coordinate response plan
• Include representatives from various disciplines and departments (clinical and nonclinical)
• Focus on both individual and institutional factors
• Adapt to changing circumstances
• Collect data and communicate to leadership
• Mental health related concerns (aggregated)
• Outcome data on Tier 2 and 3 interventions
• Ensure resources are well publicized
Organizational wellness workgroup
Resilience and Stress Management Training
Various models/curricula
Venues: • In-person• Live Zoom• Recorded
• Linked on intranet wellness site• Web-based
Cohorts• Existing teams• Multiple teams • Open to anyone
Organized by unit leaders versus individual sign-up
Nebraska Medicine Resilience Workshop
Model
• Based on PsySTART® Responder / Anticipate, Plan, Deter™ © 2003-2018, Merritt Schreiber, Ph.D. with permission
• U.S. Air Force Pre-Exposure Preparation (PEP) Training
• Plan ahead for what is likely to be most stressful and how to respond
Trained 11 behavioral health responders
• Psychologists, social workers, MD, RN, pharmacist
Training resources available at: • https://repository.netecweb.org/items/show/907)
Nebraska Medicine Resilience Workshop
• Unique challenges for HCWs
• Risk factors for psychological distress
• Definition and elements of resilience
• Identify personal signs of stress
• Identify what is likely to be most challenging
• Identify existing techniques to relieve stress
• Additional tips for coping and stress management
• Learn formal relaxation techniques
• Deep breathing and body scan exercises
• Healthy thinking (based on CBT and resilience literature)
• Gratitude
• Social Support
• Healthful sleep, eating and exercise habits
• When to seek additional help
• Where to find help
• Address common barriers to getting help (stigma, pride, embarrassment)
Workshop components
Resilience Roadmap
Participants complete throughout the workshop
Participants identify
Individual signs of stress
Elements of the response likely to be most difficult
Existing coping strategies
New coping techniques
Social supports
Also includes
Tips for healthy thinking
Apps and websites to practice relaxation techniques
Indicators for when to seek help
Resources available to employees (e.g., PiNS program, EAP, etc.)
Resilience Roadmap available at:https://repository.netecweb.org/items/show/907
Nebraska Medicine Resilience Roadmap
Nebraska Medicine Resilience Roadmap
https://repository.netecweb.org/items/show/907
Nebraska Medicine Resilience Workshop
To date73 live workshops2,397 views of recording
Universal Peer Support
Stress is an occupational hazard, not a mental health problem
Ensure everyone has a work partner with whom to check-in and provide/receive support
Pair individuals based on similar areas of practice and career stage
Encourage frequent contact to assess and validate stressors and successes, and foster social connection
Based on US military program
Examples:
• University of Minnesota Medical Center Battle Buddy Program*
• Nebraska Medicine Pandemic Partners Program
*Albott, C.S, Wozniak, J.R, McGlinch, B.P., et al. (2020). Battle Buddies: Rapid deployment of a psychological resilience intervention for health care workers during the Coronavirus Disease 2019 pandemic. Anesthesia-Analgesia, 131, 43-54.
Centralized Resource Repository
All programs and services offered by your organization (EAP, peer support, resilience workshops, etc.)Include resources for basic needs (food, transportation, housing, child and eldercare, fitness, etc.)
National programs and services for emotional / mental health support Physician Support Line – national, free and confidential (1-888-409-0141) National Suicide Prevention Lifeline (1-800-273-8255) Crisis Text Line (Text “home” to 741741) Federal Disaster Distress Helpline (1-800-985-5990) Emotional PPE Project (https://www.emotionalppe.org)
Selected stress management and well-being resources, such as tip sheets, websites and apps The Center for the Study of Traumatic Stress – resource library including material for HCWs ACGME well-being resources National Academy of Medicine Web site - resources to support provider well-being CDC website – resources for coping with stress, including first responders Apps such as COVID Coach (free) and Headspace (free for HCWs)
Example: Nebraska Medicine
Centralized Resource Repository
Framework for Workforce Support: Tier 2
• Peer support (reactive and proactive)
• Behavioral health liaisons
• Support groups / support centers
• Spiritual care
• Strategies to prevent moral injury
• Screening and referral
Peer Support
*Shapiro, J. & Galowitz, P. (2016). Peer support for clinicians: a programmatic approach. Academic Medicine, 91(19), 1200-4.
Self-referral
Proactive
• Often after adverse events and medical errors (e.g., Shapiro and Galowitz, 2016*)
• Invitation to talk openly about event, listening, reflection on feelings, reframing, sense-making, coping, closing, offer for referrals and resources
Considerations
• Staffed by BH providers versus non-BH peers
• Type of training (e.g., Psychological First Aid)
Peer Support
Nebraska Medicine Peer Support Program (#2): Self-referral→Proactive
120+ behavioral health responders identified in disaster surge plan
Training 1) Unique challenges for HCWs in a pandemic2) Psychological First Aid3) When and how to make a referral4) Self-care
Evolved from self-referral to proactive• Only 30 self-referrals after 2-3 months• Began reaching out to high-risk groups, including:
Primary nurse after death of patient HCWs placed in quarantine or isolation COVID unit staff Staff involved in stressful work-related critical incidents Trauma service MDs and APPs Hospitalist service MDs and APPs Training available at https://repository.netecweb.org/items/show/907
Peer Support
712 Referrals between 3/23/20 and 10/3/2020
Sample comments from Peer Supporters:
• “Very appreciative of the call. Is stressed but has good support and coping well at this time. Would like a follow-up call, so will plan to follow-up next week.”
• “…Feels stressed re missed work/projects. Encouraged focusing on health, taking one day at a time; encouraged deep breathing and writing down worries. Agreed to check in again next week…”
• “Offered emotional support. Baseline anxiety symptoms have worsened. Colleague feels sx's are currently manageable but will contact Dr if needs adjustment to psychotropic medication. Colleague would like a phone call next week for additional support... Contacted on [date] as planned. Colleague doing well and does not need additional follow-up. Invited to contact me anytime, ifdesired.”
• “Provided emotional support and normalized reactions. Pt is experiencing distress related to being isolated and feelings of frustration regarding how she became exposed to the virus. Indicated that they will reach out to provider if they need to talk sooner. Otherwise will plan on speaking in one week. “
• “... Provided support and reminded her to work on locating ways to reduce stress from her body. She plans on resting more andworrying less. She reports she does not need follow-up but is thankful that NMC cares”
Peer Support
Nebraska Medicine Embedded Peer Support Program (#3)
90+ employees identified by managers as informal leaders
Provide support within existing teams; managers provide "license"
Training• Unique challenges for HCWs in a pandemic• Risk factors for psychological distress• Psychological First Aid just-in-time training (brief)• 3-step model:
• Identify signs of distress• Reach out and connect• Listen and make a plan
• Resources available to colleagues• Self-care
Embedded peer supporters can consult with BH team
Training resources available at https://repository.netecweb.org/items/show/907
Behavioral Health Liaisons for High Risk Areas
In-person rounding (e.g., COVID units and ED)
• Brief consultation, support, coping strategies and
referral as needed
• Address concerns that otherwise would never hear
• Solidarity from being in the trenches with team
Attend staff meetings
• Facilitate sharing, mutual support, and coping
strategies
• Stress management training
Support Groups
In-person or telehealth
• Tailored to specific departments/disciplines versus more inclusive
• Promote reflection and discussion on the emotional impact of healthcare work; mutual support
• Psychoeducation about mental health during a crisis
Can focus on specific themes, such as grief, caregiving, family life
• Ideally co-facilitated by member of involved department/discipline and BH provider
• Balint Groups
Related intervention
• Schwartz Rounds
Support Centers / Relaxation Rooms
Often adjacent to clinical care areas
• e.g., ED and inpatient units
Space for rest and health promotion during shifts
Can include snacks, music, scents, calming visual images
Sometimes staffed by a behavioral health professional delivering Psychological First Aid (PFA)
Spiritual Care
Individual support
• Spiritual counsel, prayer, emotional support, religious support
• Values clarification
• Create rituals to honor patients, colleagues, milestones
Group support focused on specific topics
• Spiritual - focus on emotional and spiritual responses, including meaning, connection, isolation and hope (MSHS)
• Grief (MSHS)
Prevent Moral Injury
*Source: Greenberg, Docherty, Gnanapragasam & Wessely. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 2020;368:m1211 doi: 10.1136/bmj.m1211 (Published 26 March 2020)
Psychological distress from witnessing, perpetrating or failing to prevent acts that transgress core moral beliefs
• Allocating limited resources to a surge of critically ill patients
• Inability to deliver the level of care one would like to due to structural constraints (e.g., visitation policies)
• Balancing one’s own physical/mental health with that of patients
Feelings of guilt, shame and disgust
Negative thoughts about self and/or others
Can contribute to mental health difficulties
Prevent Moral Injury
*Source: Greenberg, Docherty, Gnanapragasam & Wessely. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 2020;368:m1211 doi: 10.1136/bmj.m1211 (Published 26 March 2020)
Proactively provide opportunities to discuss ethical challenges before, during and after
• Include honest assessment of what is likely to occur
• Create safe space to share emotional challenges (during and after the crisis)
• Encourage clinicians to seek support from colleagues, managers or chaplains
• Team leads and more experienced members check-in with others
• Schwarz Rounds
Monitor psychological well-being of team
• Those suffering often don’t discuss it due to shame and guilt
Provide rapid access to professional help
• Create a meaningful narrative rather than a traumatic one
Prevent Moral Injury: Managing End-of-Life Care
RN assigned an RN “extender” (palliative care nurse)
• Assists with timing and coordination of removal of life prolonging treatments
• Coordinates family visitation or video visit
• Prepares family and helps say goodbye
• Debriefs with RN afterwards
RN’s manager reaches out within 24 hours
• BH team provided managers resources for speaking about grief
Theory of grief and general principles for talking about death
Specific questions to ask
Resources and strategies to offer RNs
Behavioral health provider reaches out within 72 hours
Screening and Referral
Considerations: • Formal screening tool (e.g., PHQ-9, Maslach Burnout Inventory, WHO-5)• Whom to screen and at what frequency• How to protect confidentiality; who has access to data (e.g., third party)• How to ensure access to services for those screening positive
Example: online, anonymous screening and referral• AFSP Interactive Screening Program
• Screens for COVID-related stress and anxiety • Trained counselors at facility respond to requests for dialogue, provide
support, and connect users with resources - all anonymously• Mindwise (https://www.mindwise.org/screenings/)
• Questionnaires on a range of topics (depression, substance use, anxiety, trauma, eating disorders, overall well-being, etc.)
• Provides local resources customized by the organization when participants screen positive
Direct Mental Health Services: Tier 3
Goal: Expedited, accessible services for HCWs and family members
Strategies
• Referral line – confidential number for HCWs to find/access services
Example: Nebraska Medicine's Behavioral Health Connection – a free, confidential program to identify providers, assist with transportation, assist with prescriptions, coordinate care
• Rapid access to services (e.g., EAP, local network, own health system)
Example: Nebraska Medicine's Psychiatry and Psychology departments see any provider or family member within 1 week
Direct Mental Health Services: Overcome traditional barriers
Traditional barriers: hero culture, stigma, time, cost, lack of awareness, confidentiality
• Educational campaigns to address hero culture and stigma
• Leaders discuss their own struggles and advocate for help-seeking
• Free services (e.g., EAP, community providers)
• Telehealth
• Distribute lists of mental health professionals willing to treat HCWs for a reduced fee
Posters (e.g., nurses station, break rooms)
Periodic emails on topics like sleep, anxiety, substance use, mindfulness, relationship stress, getting help, grief, etc.
Employee forums
Daily e-newsletter
Nursing meetings
Tent cards in break rooms
Team leaders talking about own struggles
Podcasts
Get the word out!
Challenges for Healthcare Workers in a Pandemic
What about after the pandemic?
Challenges for Healthcare Workers in a PandemicPsychological Response Phases
Emotional Highs
Emotional Lows
Up to One Year After Anniversary
Trigger Events
Inventory
Anniversary Reactions
Working Through GriefComing to Terms
Setback
ReconstructionA new Beginning
HoneymoonCommunity Cohesion
Heroic
Pre-disaster
DisillusionmentWarning
Threat
Impact
Recovery Phase: Psychological Responses
Tier 3:
Tier 1:
Indicated interventions
Universal interventions
Staff have time to reflect
Most will cope successfully
• Some may experience positive change and posttraumatic growth
Some will struggle
• Intrusive thoughts
What I “should” have done differently; shame or guilt
o Dissonance with “hero” narrative may make disclosure more difficult
• Thinking differently about job
Resentment towards individuals or the organization
• Family and social disruptions
• Burnout
• Posttraumatic stressSource: The British Psychological Society (2020). The psychological needs of healthcare staff as a result of the Coronavirus outbreak.
Recovery Phase: Principles for Responding
Tier 3:
Tier 1:
Indicated interventions
Universal interventions
Consider long-term psychological needs of the workforce; not business as usual
Allow time and space for reflection and processing
• Behavioral health providers can help facilitate
Formal debriefing events with staff at all levels
• Results inform future preparedness plans
Continued communication from leadership
• Events to thank and praise staff
Ongoing needs assessment and evolving forms of support
• Screening and referral, outreach, psychoeducation
Continue to raise awareness of wellness resources
Source: The British Psychological Society (2020). The psychological needs of healthcare staff as a result of the Coronavirus outbreak.
Supporting the healthcare workforce
SummaryDuring a pandemic, HCWs are at risk for significant emotional distress
Consider interventions at each tier: Universal, selective, indicated
Build in social support
Be proactive – don’t wait for HCWs to come to you
Overcome traditional obstacles
• Embed in existing environments
• Highly visible
• Easily accessible
• Confidential
• Nonstigmatizing
Continue providing support after the pandemic ends
Supporting the healthcare workforce
Selected ReferencesSchwartz, R. et al. (2020). Addressing postpandemic clinician mental health: A narrative review and
conceptual framework. Annals of Internal Medicine, 173, 981-988.
Questions?